Rev. 10/14 PLEASE PRINT IN INK AND COMPLETE ALL INFORMATION

THE PORT OF CORPUS CHRISTI AUTHORITY

APPLICATION FOR EMPLOYMENT

The Port of Corpus Christi Authority is an Equal Opportunity Employer. Please note this application and the information provided in it is considered public record pursuant to the Tex. Gov’t Code §§ 552.001 et. seq. Upon proper request, the PCCA may be required to release this application for review by the person who requests to review it.

NAME: SS#: DATE:

First Last MI

ADDRESS:

Street City State Zip Code

BUS. HOME POSITION

PHONE: PHONE: APPLYING FOR:

MINIMUM SALARY HRS AVAIL. DATE AVAIL. TO

REQUIREMENT: TO WORK: BEGIN EMPLOYMENT:

EDUCATIONAL BACKGROUND

Type of School / Name, address and phone number of School attended / # Years completed / Degree, Major or Focus of Study
High
School
College or
University
Graduate
School
Other (Trade, Business, etc.)

MILITARY DUTY: Branch Dates of Duty: Rank at Separation:

Briefly describe your duties:

HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE (within the last 5 yrs)? NO YES

IF YES, PLACE: NATURE:

(An affirmative answer will not automatically disqualify you from being considered as a candidate for employment.)

LIST SPECIAL SKILLS OR LICENSES YOU POSSESS (typing, computer software, machines/equipment used, etc.):

REFERENCES (List at least three, persons who are not employers or relatives – Name, Occupation and phone number):

HOW WERE YOU REFERRED TO THE PORT?

HAVE YOU PREVIOUSLY APPLIED FOR EMPLOYMENT WITH THE PORT? NO YES, WHEN:

DO YOU HAVE ANY RELATIVES EMPLOYED AT THE PORT? NO YES, NAME:

DEPARTMENT:

EMPLOYMENT HISTORY (List present or most recent employer first.)

Employer Name: Address Phone Number
Dates Employed Starting / Ending Salary Job Title Name of Supervisor
List of Major Duties/Responsibilities:
Reason for Leaving: May we contact? No Yes
Employer Name: Address Phone Number
Dates Employed Starting / Ending Salary Job Title Name of Supervisor
List of Major Duties/Responsibilities:
Reason for Leaving: May we contact? No Yes
Employer Name: Address Phone Number
Dates Employed Starting / Ending Salary Job Title Name of Supervisor
List of Major Duties/Responsibilities:
Reason for Leaving: May we contact? No Yes
Employer Name: Address Phone Number
Dates Employed Starting / Ending Salary Job Title Name of Supervisor
List of Major Duties/Responsibilities:
Reason for Leaving: May we contact? No Yes

AGREEMENT (Please read the following statements carefully and initial by each paragraph):

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also understand that falsified information or significant omissions may disqualify me from further consideration for employment and/or may subject me to disciplinary action up to and including termination if discovered at a later date.

I authorize persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying resume, if any) to provide relevant information that may be required to arrive at an employment decision and release all parties from all liability for any damages that may result from furnishing same to you.

____ In consideration of my employment, if I am eventually employed by the Port, I agree to conform to the Policies and Procedures of the Port. I understand that the filing of this application does not imply that I am bound to accept employment or that I will eventually be hired by the Port.

Signature Date

APPLICANT

Flow Information

It is the policy of the Port of Corpus Christi Authority to be an EQUAL OPPORTUNITY

EMPLOYER. Employment opportunities are open to qualified applicants, based on their

aptitudes and abilities, and are not influenced by a person’s race, color, sex, age religion,

national origin or ancestry, disability or veteran status.

Pursuant to Federal regulations, the Port of Corpus Christi Authority is required to maintain

records for governmental record keeping and periodic reporting, and also to monitor our

affirmative action program. This information is not part of the selection/employment process. It

will be maintained separately from personnel files and applications for employment.

Submission of the following information is voluntary.

NAME Last ______

First ______

Middle Initial ______

SOCIAL SECURITY NUMBER ______

DATE OF BIRTH ______

SEX ¨ Male ¨ Female

VETERAN ¨ Yes ¨ No

DISABLED ¨ Yes ¨ No (physical or mental impairment that

substantially limits one or more major

life activities)

RACE/ETHNIC GROUP

¨ White

¨ Black

¨ Hispanic

¨ Asian or Pacific Islander

¨ American Indian or Alaskan Native

¨ Other